Provider Demographics
NPI:1386711901
Name:PANGILINAN, RODERICK FAJARDO
Entity type:Individual
Prefix:DR
First Name:RODERICK
Middle Name:FAJARDO
Last Name:PANGILINAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 711314
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92072-1314
Mailing Address - Country:US
Mailing Address - Phone:619-677-0598
Mailing Address - Fax:
Practice Address - Street 1:4123 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1418
Practice Address - Country:US
Practice Address - Phone:619-521-0033
Practice Address - Fax:619-521-0961
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54295122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist